The influence of integration of health-insurance schemes on catastrophic health expenditure in China: a cohort study

Abstract Background Fragmented health-insurance schemes led to inefficiency and inequality in financial protection for universal health-care coverage. The Chinese government proceeded to consolidate the urban and rural health-insurance schemes with a unified fund collection, pooling, and payment system in 2016. Our study aims to establish the effects of the integration policy on incidence and distribution of catastrophic health expenditure (CHE) in China. Methods We obtained nationally representative cohort data for analysis from five China Family Panel Studies from 2010 to 2018, which included 17 858 households from 23 provinces. Families were selected using a probability proportional to size sampling technique with implicit stratification from 25 provinces in mainland China. In this natural experimental design, the five provinces with integrated health-insurance schemes before 2016 were considered to be the treatment group, and the other 18 provinces were considered to be the control group. We used a differences-in-differences method to capture the effects of integration policy on CHE incidence, measured by whether the out-of-pocket health expenditure exceeded 25% of the total household non-food expenditure, controlling for both household characteristics and geographical fixed effects. Further, we used the concentration index to investigate changes in the distribution of CHE. Findings The incidence of CHE for total population decreased from 17·4% (95% CI 16·7–18·0, SE 0·0034) in 2010 to 13·0% (12·4–13·6, 0·0031) in 2018. The incidence of CHE in urban areas decreased from 14·1% (13·3–15·0, 0·0045) in 2010 to 9·6% (8·8–10·3, 0·0038) in 2018, whereas it declined from 20·3% (19·3–21·3, 0·0050) to 16·6% (15·7–17·6, 0·0049) in rural areas. The incidence of CHE in treatment groups reduced from 15·2% (14·0–16·5, 0·0063) in 2010 to 10·1% (9·0–11·2, 0·0057) in 2018, whereas it decreased from 18·1% (17·3–18·9, 0·0040) in 2010 to 14·0% (13·2–14·7, 0·0036) in 2018 in control groups. In addition, consolidation of health-insurance schemes decreased the incidence of CHE by 1·7% (0·68–2·73, p Interpretation The integration of different public health-insurance schemes in China might have increased the financial protection of residents covered by these schemes. However, urban–rural disparity in health insurance and unequal distribution of CHE among poor households have not altered. This study suggests that bulk purchasing and payment reform can be implemented to contain health-care costs and to refrain out-of-pocket payments, particularly for rural and population with low incomes. Funding NHC Key Laboratory of Health Economics and Policy Research, Shandong University (grant NHC-HEPR2019017).